Practice Management & Allied Staff News & Materials

Coding Corner - Mar/Apr 2010

April 1st, 2010

Post-submission claims reviews - read your EOBs!

Post-submission claims reviews, ie, reading your EOBs (Explanations of Benefits), is a critical component to an OMS' revenue stream. Failure to do so can leave legitimate monies due you on the table. There are several reasons that this process is so important.

For one, a provider can double check that an insurance carrier is processing claims correctly; for example, following coding guidelines, adhering to contractual agreements and utilizing proper adjudication methods. Upon review a provider may find, for instance, that a carrier is downcoding certain services or perhaps applying a multiple procedure reduction to a surgical service, which may or may not be appropriate. In addition, review of an EOB will inform the provider what amounts, if any, must be written off as opposed to forwarded on to a secondary carrier and/or the patient. Most importantly, however, it can alert a provider to a situation where a coding change needs to be made, such as the addition of a modifier, or a case where an appeal of a denied claim is warranted. The exercise of postsubmission claims review can also be used as an educational opportunity for coding and billing staff to aid in future claims submissions.

Being familiar with and understanding standardized claim adjustment reason codes can assist providers with post-payment claims review. These codes communicate an adjustment, meaning an explanation as to why a claim or service line was paid differently than it was billed. An example of this is the following statement: "these are non-covered services because this is not deemed a 'medical necessity' by the payer." If there is no adjustment to a claim/ line, then there is no adjustment reason code. Remittance advice remark codes should also be of interest to the provider, as they are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a claim adjustment reason code. Each remittance advice remark code identifies a specific message as shown in the remittance advice remark code list. For instance, an EOB may reflect the statement "missing/incomplete/invalid diagnosis or condition" to alert the provider to issues with the claim. Health care claim status codes conveying the status of an entire claim or a specific service line, claim status category codes indicating the general category of the status (accepted, rejected, additional information requested, etc.) further detailed in the claim status codes, and health care services decision reason codes used to indicate the primary reason for the certification action code assigned as part of a health care services review, are worthy of note.

If the above are not reasons enough to prompt you to conduct postsubmission claims reviews, remember also that carriers may perform their own retrospective reviews and may attempt to recoup monies on claims reimbursements deemed overpayments. It is best if such cases are identified up front by the provider and immediately researched to prevent carrier refund requests or withholding of future payments from occurring.

OMSs, coders and billing staff interested in learning more about this and other general OMS billing issues are encouraged to participate in the AAOMS OMS Billing Conference, held immediately following AAOMS Beyond the Basics Coding Workshops. For more information on 2010 offerings, visit http://www.aaoms.org.

2010 brings several new and revised codes of which an OMS must be aware. Among them are CPT soft tissue tumor excision codes 21011 - 21016. These new and revised codes are logically placed in the "Surgery/ Musculoskeletal System" chapter of CPT, under the subsection "Head."

These new codes fill a gap for OMSs and allow more precise coding of soft tissue tumor excisions of the face and scalp. They were developed as part of a larger CPT effort to look at soft tissue tumor excision codes throughout all body systems and to develop consistent terminology. Prior to 2010 code 21015 (radical resection of tumor (eg, malignant neoplasm), soft tissue of face or scalp) was the only code available to describe a soft tissue tumor excision of the face or scalp. The code is now revised, accommodating more precise reporting of the specific size of the tumor being removed. The new codes provide a mechanism for reporting the removal of tumors not requiring a radical resection, such as some non-malignant neoplasms, and also incorporate size.

As mentioned, these new codes were developed as part of a larger effort to look at all soft tissue tumor excision codes in CPT. In addition to the new codes developed for the face and scalp, two new codes were also created for the neck. They are placed in the "Surgery/ Musculoskeletal System" chapter of CPT, under the subsection titled "Neck (Soft Tissues) and Thorax." These new codes are assigned numbers 21552 (excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater) and 21554 (excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater). If one turns to the 2010 CPT manual, looking for codes 21552 and 21554 in a purely numerical fashion, one will note that codes 21552 and 21554 are, as one would expect, listed beneath code 21550. What one may find interesting, however, is that next to each code is a note that reads "Code is out of numerical sequence. See 21550 - 21632," rather than the descriptor of the procedure that one would expect to find. If one follows this direction, perusing the codes in the 21550 - 21632 range, one will find code 21552 listed out of numerical sequence beneath code 21555. Code 21554 is also out of sequence found immediately following code 21556. "Out of sequence" codes 21552 and 21556 are preceded by the "#" symbol, new to the 2010 CPT manual, representing a "resequenced code." Immediately following each "out of sequence" code is the code's descriptor.

The above is referred to as the "CPT Resequencing Initiative." The CPT Editorial Panel rolled out this new procedural process with CPT 2010 in an effort to support standard terminology principles in the CPT coding development and maintenance process. In addition, it is believed this will alleviate issues with code renumbering that have occurred in the past. For instance some may recall issues related to CPT injection codes (currently numbered 96372 - 93375) over the last several years wherein code descriptors did not change but code numbers did. This caused a fair amount of confusion, which would have been alleviated by retaining existing code numbers and instead resequencing code placement so that concepts could be logically grouped together. With the evolution of electronic coding products, it is envisioned that numerical sequencing of codes will become even less important in the future as users will rely less heavily on code numbers themselves but rather focus on logical groupings of concepts. According to the AMA "Resequencing extends the existence of the current 5-digit numbering scheme, allows for growth and flexibility of CPT content, and improves the use of CPT codes in electronic products." While in 2010 the resequencing initiative does not really impact the majority of CPT codes used by OMSs, it may in the future and is thus worthy of note. A list of all codes affected by the resequencing initiative may be found in Appendix N, new to the 2010 CPT manual. At present 27 codes are affected.

A complete list of code changes (additions, revisions and deletions) may be found in Appendix B of the 2010 CPT manual. OMSs are encouraged to purchase new CPT and ICD-9-CM manuals each and every year and new CDT manuals every other year. Information on ordering via Decision Health is available here.